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DocuSign Envelope ID: 2F173BE3-D39C47D3-A993-65B9F76377E9 <br /> SANJOAQUIN Environmental Health Department <br /> — COU NTY -- <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ■ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # CAR000227926 t Project Contact & Telephone # 425.656-1064 <br /> CFacility Name Costco Gasoline (Loc. 38) Phone # 209-47&2040 <br /> I Address 1630 E Hammer LN , Stockton , CA 95210 <br /> I Cross Street Prontaoe Road <br /> T <br /> Y Owner/Operator Tim Hurlocker Phone # 425-818-3100 <br /> C Contractor Name Wayne Perry, Inc. ATT: Tom Faludy Phone # 714-826-0352 <br /> o _� <br /> N Contractor Address 8281 Commonwealth Avenue, Buena Park, CA 90621 CA Lic # 300345 Class A, 210 10, <br /> T — _ __ C61 /D40 HAZ C57 <br /> R <br /> A Insurer Everest National Insurance Co. Work Comp # CA10003737211 <br /> T ICC Technician's Name Seo Attached List Expiration Date See Attached List <br /> R ICC Installer's Name See Attached List Expiration Date See Attached List <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Ln. 87 piping sump, 91 leak delaetor, UDC 112. otc.) Installed <br /> T 20,000 Gasoline (regular) 2004 <br /> A 20,000 Gasoline (regular) 2004 <br /> N <br /> K 20,000 Gasoline (premium) 2004 <br /> 1 , 500 Gasoline Additive (Lubrizol) 2013 <br /> P U Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions ) <br /> A i f <br /> N Plan Reviewers Name G�k. 1 YDate orl 10 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA! <br /> Applicant's Signature Title Authorized Agent of Owner Date <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e .g , property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME M . Alexia Iniques TITLE Authorized Agent of Owner PHONE # 425-251 -6222 <br /> ADDRESS c/o Barghausen Consulting Engineers, Inc. 18215 72nd Ave. S. Kent, WA 98032 <br /> Doc-uSllgned by: <br /> SIGNATURE F '7 ' ° �'^^ " � ° DATE 2 /9 /2021 <br /> B420D6A78BOF48D,,, <br /> 2of6 <br />